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Abdominal Trauma 185
Erect Plain Abdominal Radiograph
An erect plain abdominal radiograph should include the chest and pel-
vis. The findings should be correlated with clinical findings to avoid
unnecessary laparotomy. Findings may include free peritoneal air
(Figure 29.1) in intestinal rupture, medially displaced gastric or colonic
gas shadow in splenic rupture, or generalised ground-glass appearance
of massive intraperitoneal or retroperitoneal haemorrhage. Rib and
pelvic fractures may be seen.
Computed Tomography
The contrast-enhanced (intravenous (IV) or enteral) computed tomogra-
phy (CT) scan is probably the most useful imaging modality to identify
and characterise solid and hollow visceral injury. It provides clear and
accurate imaging of the intraabdominal organs, including intestinal
perforation and injuries to retroperitoneal structures. The CT scan may
show a contrast blush—a well-circumscribed area of contrast extrava-
sation that is hyperdense with respect to the surrounding parenchyma
(Figure 29.2). The contrast blush is a specific marker of active bleed-
ing associated with a higher rate of operative intervention in children.
Notwithstanding whether a contrast blush is present, however, the
decision to operate should be made on the basis of clinical response to
resuscitation; clinically stable patients with a contrast blush can be suc-
9
cessfully treated nonoperatively. Although a CT scan is widely accepted
and gives accurate results with few false-positive and false-negative
interpretations, it may not be readily available in some centres in Africa.
Exploratory Laparoscopy and Laparotomy Figure 29.1: Free air in the peritoneal cavity due to intestinal perforation from
When available, laparoscopy can be valuable in the diagnostic evalua- blunt trauma.
tion of patients who are haemodynamically stable but there is a strong
suspicion of intraabdominal organ injury.
Laparotomy may be needed for definitive diagnosis and treatment. It
is indicated in the patient who responds poorly to adequate resuscitation
efforts consisting of greater than 40 ml/kg of crystalloids or one-half the
child’s blood volume within the first 24 hours after injury. Blood should
be grouped, cross-matched, and stored for a transfusion, when necessary.
To summarise, the surgeon in Africa, and indeed elsewhere,
must be proficient in the clinical evaluation of the traumatised child
with suspected intraabdominal injuries, even with the availability of
10
advanced imaging techniques. The value of clinical examination was
demonstrated in a study by Chirdan et al. showing a drastic reduction in
the rate of laparotomy without compromising outcome in resource-poor
settings when a simple management algorithm is used. The algorithm
includes clinical examination and simple radiology and laboratory tests. 4
Treatment
Liver and Spleen
The liver and spleen are the solid organs most frequently injured in
blunt trauma.
Source: Courtesy of Manuel Meza, MD, Children’s Hospital of Pittsburgh, Pittsburgh,
Nonoperative management Pennsylvania, USA.
Most injuries stop bleeding spontaneously and can be managed nonoper- Figure 29.2: Contrast blush seen on CT scan in a patient with grade 4 splenic
atively, but the child must be haemodynamically stable. Nonoperative laceration (arrow), indicating active bleeding. Note the haemoperitoneum over
11
management entails admission into the intensive care unit, where avail- the liver.
able. The child is placed on strict bed rest, and then carefully and repeat-
edly monitored. Vital signs are recorded every half hour until stability
where a follow-up CT or abdominal ultrasound (US) scan done before
is achieved. The abdomen is examined every 4 hours for increasing
discharge from hospital helps the surgeon decide whether further
distention and tenderness. Increasing distention may indicate intraperi-
hospital stay is necessary.
toneal haemorrhage or gaseous distention, and further evaluation should
The nonoperative management approach is not without hazards,
be done immediately to ascertain whether operative intervention is
such as missed hollow viscus injuries and rebleeding. In the following
necessary. Supportive laboratory investigations are done regularly. Any
situations after blunt trauma, nonoperative management may not be
anaemia or fluids and electrolyte derangements are treated promptly.
possible, and operative treatment then becomes necessary:
If nonoperative management is successful, the activity of the child,
1. haemodynamic instability;
such as sports or heavy work at school or home, must be limited for
about 4 weeks. In Western countries, follow-up imaging is often not 2. transfusion requirement is greater than half of estimated blood
needed because patients have easy access to trauma centres in the event volume (estimated blood volume is 70–80 ml/kg body weight);
of rebleeding. This is not the case, however, in the African setting, 3. presence of associated injuries requiring surgery;